Today’s academic faculty was typically trained under an education system based entirely on didactic lectures. However, if the aim is to teach thinking or change attitudes beyond the simple transmission of factual knowledge, then lectures alone, without active involvement of the students, are not the most effective method of teaching. If the goals of teaching are to arouse and keep students’ interest, give facts and details, to make students think critically about the subject, and to prepare for independent studies by demonstration of problem solving and professional reasoning, then only two of these purposes are suited to didactic lectures. The problem then is how to organize lecture material so that individual student’s learning needs are better addressed. The education literature suggests that instruction include a variety of activities designed to stimulate individual thought. These activities include small group discussion, working problems during lecture time, questions included in the lecture, and quizzes at the end of lecture, among others. The current study was undertaken to examine the feasibility of using these types of interactive learning techniques in an otolaryngology residency program. Possibilities considered in the current study include standard interactive lecturing, facilitated discussion, brainstorming, small group activities, problem solving, competitive large group exercises, and the use of illustrative cliff hanger and incident cases. The feasibility of these methodologies being effectively incorporated into a residency curriculum is discussed.
Today’s academic faculty were typically trained under an education system based entirely on didactic lectures. Because the choice of teaching method is usually based on familiar methods, didactic lectures have persisted. However, if the aim is to teach thinking or change attitudes beyond the simple transmission of factual knowledge, then lectures alone, without active involvement of the students, are not the most effective method of teaching . The goals of teaching as described by Isaacs are to (1) arouse and keep students’ interest, (2) give facts and details, (3) make students think critically about the subject, and (4) prepare students for independent studies by demonstration of problem solving and professional reasoning . Isaacs notes, however, that only two of these purposes are well suited to didactic lectures. The problem then is how to organize lecture material so that individual student’s learning needs are better addressed. Gibbs suggests that lecture sessions contain a variety of activities designed to stimulate individual students to think, including small-group discussion, working problems during lecture time, questions included in the lecture, and quizzes at the end of lecture, among others .
The current article examines the feasibility of using these types of interactive learning techniques in an otolaryngology residency program. Other possibilities include standard interactive lecturing, facilitated discussion, brainstorming, small-group activities, problem solving, competitive large-group exercises, and the use of illustrative cliff-hanger and incident cases. The feasibility of these methodologies being effectively incorporated into a residency curriculum is discussed.
Adult learning theory
As adult learners, physicians have many different learning styles, and any planned education intervention should account for these differences. Malcolm Knowles is best known for the theory of andragogy, the art and science of helping adults learn, as contrasted with pedagogy, the art and science of helping children learn . Knowles assumed that adults and children learned differently based on five humanistic assumptions :
- 1.
As a person matures, his or her self-concept moves from that of a dependent personality toward one of a self-directing human being.
- 2.
An adult accumulates a growing reservoir of experience, which is a rich resource for learning.
- 3.
The readiness of an adult to learn is closely related to the developmental task of his or her social role.
- 4.
There is a change in time perspective as people mature—from future to immediate application of knowledge; thus an adult is more problem centered than subject centered in learning.
- 5.
Adults are motivated to learn by internal factors rather than external ones.
Compared with children, adults have significant experience and prior knowledge from which they draw connections and parallels that help to define and categorize new knowledge. The more alike new knowledge is in organization and content to old knowledge, the more easily this knowledge can be assimilated. On any given topic, learners differ greatly in the depth and accuracy of prior knowledge. More than likely, the knowledge will be fragmented and incomplete. In a standard didactic lecture, there is no opportunity for the lecturer to gauge prior knowledge of the learner and, therefore, the class’ learning effectiveness may be quite diverse. Some students may reinterpret what they hear to fit preexisting misconceptions. It will be necessary for some students, therefore, to unlearn some of what they already know and reorganize their knowledge base. Thus the assessment of prior knowledge is critical to the lecturer.
As adults grow and change in the learning experience, these changes should be recognized, making feedback essential. The basis of andragogy is often used in the teaching of adults. Putting this theory to work in the classroom involves an awareness of the basic principles that underlie these assumptions. The classroom should be a safe, comfortable environment where facilitation, rather than lectures, is used as a teaching style. The facilitator should promote understanding and retention along with the application of the material to the life experience of the students. The curriculum should be problem centered whereas the learning design should promote information integration.
Life situations of physicians have a critical impact as well. McClusky, who introduced the “theory of margin,” believed that adulthood involved continuous growth, change, and integration, in which constant effort was required to manage the energy available for meeting the normal responsibilities of living . He envisioned margin as a formula, which expresses a ratio or relationship between “load” (of living), and “power” (to carry the load). Load is “The self and other demands required by a person to maintain a minimal level of autonomy” and power “the resources, ie, abilities, possessions, position, allies, etc., which a person can command in coping with load.” For the learner to meet the demands of life, combined with learning needs, power must exceed load. Thus, margin enables the individual to take on more stimulating activities, such as educational opportunities, and integrate them into his or her lifestyle. McClusky’s theory is appropriate because it deals with events and transitions common to all adult learners. Educators aware of this theory can more effectively create a learning environment suited to the needs of the learner. Increased load due to unrealistic work assignments, undue stress caused by uncertainty, and unresolved social issues can affect how well the learner can cope. At the same time, learning can provide surplus power, which can be a significant impetus in achieving various goals.
Knox’s (1980) proficiency theory also deals with an adult’s life situation. He defines proficiency as “the capability to perform satisfactorily if given the opportunity.” This performance involves some combination of attitude, knowledge, and skill. The purpose of adult learning is to “enhance proficiency to improve performance.” Central to this theory is the belief that a discrepancy exists between the current and desired level of proficiency. This discrepancy is the impetus that motivates the adult to seek a learning experience that will increase proficiency. A model that represents the theory would include the following interactive components: “the general environment, past and current characteristics, performance, aspiration, self, discrepancies, specific environments, learning activity, and the teacher’s role .”
Specific educational needs of otolaryngology residents and potential barriers
Medical knowledge
Spread over 4 years, the otolaryngology residency is tightly packed with didactic and self-directed learning in basic science and medical knowledge and procedural skills training. A recent review of the American Board of Otolaryngology’s medical knowledge content requirements revealed over 300 topics to be mastered before board certification. The requirement for medical knowledge is tempered by the development of clinical skills through other means such as practical experience as well as other obligations, including research and community service. Owing to the nature of residency training, didactic instruction time in residency programs is limited. With the advent of work-hour restrictions, most training programs lack sufficient lecture time to thoroughly cover the curriculum mandated by the Accreditation Council for Graduate Medical Education in the available training period. Otolaryngology didactic sessions are therefore content heavy and must be performed in a time-efficient manner to accommodate still further content in other areas.
Motivation for change and learning
Much has been written about innovative teaching and learning techniques in undergraduates. Physicians in training represent a substantially different group of learners than undergraduates, however. Once a strong professional identity has formed— usually after the first year of training—resident learning may be described similarly to that of practicing physicians by the “change model” of Fox and colleagues . In interviews with over 300 practicing physicians, the authors found that the desire to learn and change can come from professional, personal, and social reasons. In their experience, the most common reasons for change included a desire for general competence or the recognition of a changing practice environment (eg, competition, improved patient self-education, and Internet access). Resident physicians are likely similarly motivated by a desire to strengthen professional roles and identity, gain competence, and deal with expected clinical challenges. Geertsma and colleagues identified three stages to learning in practicing physicians: deciding on whether to take on a learning task to address a problem, learning the knowledge and skill anticipated to resolve the problem, and gaining experience in what has been learned. Residents differ from practicing physicians under Geertsma’s model in that they do not have the luxury of choosing whether to take on a new learning task: all learning is new and therefore necessary. The limitation of the change model is the mismatch between real and perceived learning need areas, an observation that applies equally to both resident and practicing physician learners. The instructor must nevertheless be aware of the need to link learning experiences to the residents’ future practice in order to obtain the necessary “buy-in” for whole-hearted participation.
Development of other skills in residency training
Part and parcel to residency training is functioning within a team, professional identification, and developing rapport with patients and other health care workers. Thus, learning exercises that emphasize team building, interpersonal skills, and leadership skills further the professional development of young practitioners. Finally, upon graduation residents leave the nurturing training environment and go off into distant areas to practice and become local and regional experts. Residents need to be encouraged, therefore, to make the transition from passive to independent learning, study, and professional development.
Needs assessment: focus group results
A focus group was conducted with otolaryngology residents in training to discuss innovative learning strategies. In summary, residents (1) expressed a desire to maintain the status quo and avoid complex exercises given the available lecture time, (2) considered attempts at innovation as “too experimental” or a “waste of time,” and (3) were concerned about extending the topic outside the available lecture period into personal time. Finally, residents requested the inclusion of pictures, illustrations, and videos where applicable, as well as hands-on techniques. The general consensus was that lectures should build on what has been seen or experienced clinically; residents may have difficulty learning in the abstract but are greatly interested when they have experienced a clinical problem for which they are unaware of or unable to find a solution.
Specific educational needs of otolaryngology residents and potential barriers
Medical knowledge
Spread over 4 years, the otolaryngology residency is tightly packed with didactic and self-directed learning in basic science and medical knowledge and procedural skills training. A recent review of the American Board of Otolaryngology’s medical knowledge content requirements revealed over 300 topics to be mastered before board certification. The requirement for medical knowledge is tempered by the development of clinical skills through other means such as practical experience as well as other obligations, including research and community service. Owing to the nature of residency training, didactic instruction time in residency programs is limited. With the advent of work-hour restrictions, most training programs lack sufficient lecture time to thoroughly cover the curriculum mandated by the Accreditation Council for Graduate Medical Education in the available training period. Otolaryngology didactic sessions are therefore content heavy and must be performed in a time-efficient manner to accommodate still further content in other areas.
Motivation for change and learning
Much has been written about innovative teaching and learning techniques in undergraduates. Physicians in training represent a substantially different group of learners than undergraduates, however. Once a strong professional identity has formed— usually after the first year of training—resident learning may be described similarly to that of practicing physicians by the “change model” of Fox and colleagues . In interviews with over 300 practicing physicians, the authors found that the desire to learn and change can come from professional, personal, and social reasons. In their experience, the most common reasons for change included a desire for general competence or the recognition of a changing practice environment (eg, competition, improved patient self-education, and Internet access). Resident physicians are likely similarly motivated by a desire to strengthen professional roles and identity, gain competence, and deal with expected clinical challenges. Geertsma and colleagues identified three stages to learning in practicing physicians: deciding on whether to take on a learning task to address a problem, learning the knowledge and skill anticipated to resolve the problem, and gaining experience in what has been learned. Residents differ from practicing physicians under Geertsma’s model in that they do not have the luxury of choosing whether to take on a new learning task: all learning is new and therefore necessary. The limitation of the change model is the mismatch between real and perceived learning need areas, an observation that applies equally to both resident and practicing physician learners. The instructor must nevertheless be aware of the need to link learning experiences to the residents’ future practice in order to obtain the necessary “buy-in” for whole-hearted participation.
Development of other skills in residency training
Part and parcel to residency training is functioning within a team, professional identification, and developing rapport with patients and other health care workers. Thus, learning exercises that emphasize team building, interpersonal skills, and leadership skills further the professional development of young practitioners. Finally, upon graduation residents leave the nurturing training environment and go off into distant areas to practice and become local and regional experts. Residents need to be encouraged, therefore, to make the transition from passive to independent learning, study, and professional development.
Needs assessment: focus group results
A focus group was conducted with otolaryngology residents in training to discuss innovative learning strategies. In summary, residents (1) expressed a desire to maintain the status quo and avoid complex exercises given the available lecture time, (2) considered attempts at innovation as “too experimental” or a “waste of time,” and (3) were concerned about extending the topic outside the available lecture period into personal time. Finally, residents requested the inclusion of pictures, illustrations, and videos where applicable, as well as hands-on techniques. The general consensus was that lectures should build on what has been seen or experienced clinically; residents may have difficulty learning in the abstract but are greatly interested when they have experienced a clinical problem for which they are unaware of or unable to find a solution.
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